Postpartum Exercise Clearance Form
Complete this Postpartum Exercise Clearance Form to determine readiness for postpartum exercise.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email
*
example@example.com
Date of Delivery
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Delivery
*
Vaginal
Cesarean
Other
Were there any complications during pregnancy, delivery, or postpartum?
*
No
Yes (please specify below)
If yes, please specify complications
Are you currently experiencing any of the following? (Select all that apply)
*
Abnormal vaginal bleeding
Pelvic or abdominal pain
Incontinence (urinary or fecal)
Wound healing issues
None of the above
Other
Medical Provider’s Assessment and Clearance (to be completed by provider): Please indicate if the patient is cleared to begin or resume postpartum exercise.
*
Cleared for exercise
Not cleared for exercise
Provider Name and Signature
*
Submit
Submit
Should be Empty: